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WAL-MART PHARMACY 10-1868
FQHCLA119 Community Clinical Services, Inc.
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Covered Entity Details
Entity Name
Community Clinical Services, Inc.
Subdivision Name
B Street Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA119
Entity Address
57 Birch Street
Lewiston, ME 04240-7415
Grant Number
LALCS00085
Participating Start Date
4/1/2001
Last Recertification Date
3/3/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1868
Pharmacy Address
100 MT AUBURN AVE
AUBURN, ME 04210
Pharmacy Comments
Contract Details
Approval Date
10/12/2012
Contract Begin Date
10/12/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JAMES LYSEN, EXECUTIVE DIRECTOR
(207) 513-3897
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/19/2012
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